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Sunday, April 26, 2015

Nursing Care for the Patient Experiencing Hypovolemic Shock

What is Hypovolemic Shock?

Medically, shock simply means that the tissues of the body aren't receiving adequate oxygen or nutrients and this leads to cell death. There are several different types of shock: septic shock, due to bacteria infection; neurogenic, involving the spinal cord; anaphylactic, due to an allergic reaction; cardiogenic, due to heart damage; and hypovolemic shock, due to a loss of blood/fluids.

This post will cover hypovolemic shock. What it looks like and how we treat it.

Presentation of Hypovolemic Shock

There are four different classes to stage the severity of shock in the patient. Since brevity be the soul of wit (thank you, Shakespeare) I'll keep it short. Basically the blood loss can can range from 750 mL to greater than 2000 mL. Blood pressure will decrease more with increasing severity. Brain and heart tissues are still being perfused as long as the MAP stays above 60. Blood is being shunted away from extremities to vital organs. The body is compensating the lack of oxygen by increasing the heart rate and respirations. The body's tissues need oxygen since they're losing blood, so that's why you'll see those presenting factors. The patient will range from feeling anxious to being very lethargic and confused.

Who's at Risk for Hypovolemic Shock?

Think about the different ways a person can lose an excess amount of blood/fluids. These patients are probably a trauma patient. As I type this, Jay Gatsby is bleeding profusely into his pool. I'm watching The Great Gatsby. Please, I really do hope if you're reading this that you've also read/watched The Great Gatsby and didn't picture me sitting here smug behind a computer screen looking over at some guy with a gunshot wound and saying, "Cool story, bro." No. no no no.

Anyways, these patients are gunshot victims, amputees, lacerations, open fractures, etc... These are examples of losing blood externally. You can also lose blood internally. Examples would be a major closed fracture, or bleeding varices. It might not be hemorrhaging that sends the patient into hypovolemic shock. It could also be from a loss of fluids from burns, diabetes insipidus, excessive vomiting/diarrhea.

Treatment

Give Fluids

You'll want to start giving the patient fluids as soon as possible. In order to do so you need access. Start as big of an IV as you can. Think about it, you'll be able to dump more fluids into the patient with a bigger gauge. You might also use pressure to pump the fluids into the patient faster. You can also use larger diameter tubing to increase the amount.

Lactated Ringers is the preferred fluid to give the patient. Normal Saline can be used too but remember that it has a high amount of chloride (154 meq) and therefore can raise the patient's chloride levels. You'll also want to think about warming these fluids to prevent the patient from experiencing hypothermia. Just be careful giving LR if the patient has hyperkalemia. Remember LR has 4 meq of K. Also, you can't use LR with blood products. Very important!

Colloids (ex: Albumin, Dextran)could also be ordered, but they're more expensive. You don't need as much of a colloid vs. a crystalloid. So there are advantages. The crystalloid can accumulate more edema because 3.4 of it will be in interstitial space an hour after administering. But crsytalloids are cheaper and pretty much always available.

Blood Products be careful and monitor the patient for hyperkalemia. When the RBC enter the patient's body and are reoxygenated, they take on extracellular potassium. This can lead to cardiac arrest. Of course we don't go giving blood out willy nilly. The patient would have to have lost about a liter of blood before we'd start giving it. There can be several complications. It could be against the patient's beliefs. So what I'm getting at is that this is an option, but probably not option A. It totally all depends on the clinical picture of the patient.

Evaluation

So now that you've given the patient some form of fluid, you need to evaluate the intervention. (Dear god. Don't you just hate doing this on care plans. Gag.) To determine if you're giving the correct fluid, or need to increase/decrease the amount given here are some things you'll want to pay attention to:

Blood pressure

Heart rate

Level of consciousness

Urine output

Hematocrit/Hemoglobin

Arterial blood gasses

Lactate- can show you an indirect measure of oxygen deficiency 2.0 mmol/L is abnormal. 4.0 or higher is significantly elevated.

Electrolytes: potassium, sodium, calcium

Signs of cerebral swelling-- this is when NS would be a better choice than LR

Body weight

Sum Up

"Let me explain. No. No time. Let me sum up." Don't you just love The Princess Bride? I could never work OB. Do you know how many times I would shout "Inconceivable!" Yeah. That's probably a good thing I don't plan on working OB. That could go over very badly.... Sorry!

So basically, if your patient is having major bleeding (internal or external) they could easily go into hypovolemic shock. You need to start a large bore IV on them asap. Probably two IVs. 16 gauge or larger. (You got this chicka! or Chico for our Murses.) Expect to give the patient some fluids. LR or NS are probably most likely. You also probably want to track down a fluid warmer. Evaluation of the status of the patient will involve looking at labs and vital signs.

Badda bing, badda boom. Hypovolemic shock.

What are some of your IV insertion tips for starting a large bore IV emergently? Share your wisdom below! We love reading your comments.